REGISTRATION FORM

Name (Last, First)
Organization
Street Address
City
State
Country
Zip or Postal Code
Telephone
Fax
E-Mail Address




Fees (in Euros): 

Conference Package (including conference, snacks, lunches, banquet and field trip) € 125

          

Package excluding field trip for participants from Central Asia and Iran € 20

Please indicate your preference for vegetarian meals, if any
Vegetarian

                    Method of Payment

a) Credit Card
Type of Card     VISA MasterCard EuroCard
Here are the details of my credit card for immediate on-line registration:
   Name on Card (print)
   Number
01 02 03 04 05 06 07 08 09 10 11 12 2018 2019 202020212022 2016 2017 Expiration Date
01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birthdate (mandatory: month-day-year)

Signature (not needed for online registration):_____________________________

 

I will mail the details of my card with a printed and signed copy of this form

b) I prefer not to use a credit card and am sending a printed and signed copy of this form with details of my bank draft. (Note that we should receive the amount net of any bank fees charged by your bank.)

c) I am a participant from Central Asia and Iran and will register at the door.

If you choose option (a) but do not register online, please fax or mail registration forms (including details of your credit card) to:
CESNUR
Via Confienza 19
10121 Torino, Italy
Fax: +39-011-541905

If you select option (b) please mail or fax forms to CESNUR, and send bank drafts to CESNUR PIEMONTE as follows
Name of bank: Deutsche Bank, Via Viotti 4/D, 10141 Torino, Italy
Account number: 033719
ABI Code: 03104
CAB Code: 01000
IBAN: IT36S0310401000000000033719
SWIFT CODE: DEUT IT MM TOR